Ppt 6 - History Taking

8/17/2019 Ppt 6 - History Taking

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Basic History Taking

Tim Communication Skill FKUB



Communication + History Taking

Communication : How to ask

(Bagaimana cara bertanya) History taking : Wat wil be

aske! (Apa yang akan

!itanyakan )





Te Structure o$ a Basic e!icalHistory

Basic "n$ormation o$ te #atient

History o$ ,resent "llness (H,")

,ast e!ical History (,H)e!ications

Family History

Social History (inclu!e! smokingbea*ior- alcool- #ysical

acti*ity)



Basic "n$ormation o$ te#atient

name, age, address, sex, ethnicity, occupation, religion, marital status.



History o$ ,resent "llness(H,")

Start $rom Cie$ Com#laint (CC) atauKeluan Utama

Cie$ Com#laint : why patient here--use patient's own words

One sentence that covers the dominant reason(s) for

hospitalization

Usually a single symptoms, occasionally more than one

complaints eg: chest pain, palpitation, shortness ofreath, an!le swelling etc

"hat rings your here# $ow can % help you# "hat seems to

e the prolem#



/am#le o$ History ,resent "lnessSeorang 0aki1laki berusia 23 taun

!atang ke U4 !engan mengelusakit ke#alaSakit ke#ala !irasakan se5ak 6 ariyang lalu' Sakit ke#ala !irasakan !i

ke#ala sebela kanan' Sakit!irasakan se#erti !iremas (cekot1cekot)' Sakit menyebar ke bola matasebela kanan- makin lama makinmemberat' Sakit !irasakan terusmenerus- meningkat saat menun!ukatau su5u!' Sakit berkurang saat

#en!erita berbaring'st7'



etails o$ History o$ ,resent "llness

,ysician asks

8uestions to!iscussing te!etails o$ te

cie$com#laint'



History o$ ,resent "llness answers8uestions o$ ''

Wen te#roblem

began- wat an! were tesym#toms are-

wat makeste sym#tomsworse or

better'



History o$ ,resent "llness $or ,ain

Timing (Wen)

0ocation (Were)

.a!iation (9n! out te

#ain ra!iates)Caracter (Wat is it

like)

Se*erity (How ba! is

it),rogressi*ity

;ggra*ating <;lle*iating $actors



;gar u!a iingat untuk ,ain

%osition=site

'e*erity > ow it a?ects !aily work=#ysical acti*ities' Wakes im

u# at nigt- cannot slee#=!o any work'

Relationsi# to anyting or oter bo!ily $unction=#osition'

Ra!iation: were mo*e! toRelie*ing or aggra*ating $actors > any acti*ities or #osition

&uality- nature- caracter > burning sar#- stabbing- crusing@ also

e#lain !e#t o$ #ain > su#er9cial or !ee#'

iming > mo!e o$ onset (abru#t or gra!ual)- #rogression

(continuous or intermittent > i$ intermittent ask $re8uency an!nature')

reatment recei*e! or=an! outcome'

$nset o$ !isease



/am#le :Cie$ Com#laint : a!a nyeri

Timing : !a!a nyeri se5ak 6 5am yang lalu

Wy : !a!a nyeri saat menarik becak

.a!iation : Ayeri men5alar ke lengan kiriCaracter : Ayeri se#erti !itusuk > tusuk

Se*erity : Ayeri !irasakan sangat berat inggakeluar keringat !ingin

,rogressi*ity : !alam 6 5am Ayeri bertamba ebat;ggra*ating an! alle*iating : Ayeri memberat saat

!ibuat ber5alan- nyeri berkurang 5ika !i#akaiberbaring



,ast e!ical History Tis soul! inclu!e any illness (#ast) $or

wic te #atient as recei*e! treatment'

Start by asking te #atient i$ tey a*e any

me!ical #roblems' "$ you recei*e little=nores#onse- te many 8uestions can el#unco*er im#ortant #ast e*ents

"$ #atient recei*e little=no res#onse

Ha*e tey e*er recei*e! me!ical care"$ so- wat #roblems=issues were a!!resse!

Was te care continuous or e#iso!ic



%ast )edical *istory Ha*e tey e*er

un!ergone any#roce!ures- 1

.ays- C;T scans-."s or oters#ecial testing

/*er been

os#italie! "$ so-$or wat



%ast 'urgical *istory(%'*#

Were tey e*er

o#erate! on- e*en asa cil!

Wat year !i! tisoccur

Were tere anycom#lications

"$ tey !on&t know tename o$ te o#eration-

try !etermine wy it





Current )edications- %rescription and.on/%rescription

e!ication ose ;mount Fre8uency



Allergies0Reactions

"!enti$y tes#eci9creaction tat

occurre! witeacme!ication'



Allergies0Reactions

Ha*e teye#erience! any

a!*erse reactions tome!ications

wat te eact natureo$ te reaction

;na#ylais isabsolutecontrain!ication ;ras !oes not raise

te same le*el o$concern'



1amily *istory "n #articular- you

are searcing $oreritable illnessesamong 9rst orsecon! !egreerelati*es'

/am#le : Heart!isease-congenitalabnormalities-Stroke- iabeteselitus



'ocial *istory

;lcool "ntake

Cigarette smoking %ter rug Use

arital Status

Seual History

Work History

%ter 7' tra*el



'mo2ing *istory

Ha*e tey e*ersmoke! cigarettes

"$ so- ow many#acks #er !ay an!$or ow manyyears

Filtere! or non9ltere! cigarette



Alcohol o tey !rink alcool

"$ so- ow muc #er!ay an! wat ty#e o$!rink

/ncourage tem to beas s#eci9c as #ossible'

"$ tey !on&t !rink on a!aily basis- ow muc

!o tey consume o*era week or mont



3or20*obbies0$ther Wat sort o$ work

!oes te #atient !o Ha*e tey always

!one te same ting

o tey en5oy it "$ retire!- wat !o tey

!o to stay busy ;ny obbies

,artici#ation in s#ortsor oter #ysicalacti*ity

Were are tey $romoriginally



.e*iew o$ Systems (.%S)

&haracterize patient's overall health status

eview systemssymptoms from head to toe

'ystem Revie4



'ystem Revie4

Respiratory 'ystem•Coug(#ro!ucti*e=!ry)•S#utum (colour- amount-smell)•Haemo#tysis

•Cest #ain•S%B=ys#noea• Tacy#noea•Hoarseness•Weeing

Cardiovascular•Cest #ain•,aroysmal Aocturnal ys#noea

•%rto#noea•Sort %$ Breat(S%B)•Coug=s#utum (#inkis=$rankbloo!)•Swelling o$ ankle(S%;)•,al#itations•Cyanosis

5astrointestinal0Alimentary•;##etite (anoreia=weigtcange)•iet•Aausea=*omiting

•.egurgitation=eartburn=Datulence•iEculty in swallowing•;b!ominal #ain=!istension•Cange o$ bowel abit•Haematemesis- melaena-

aematocagia• aun!ice

5eneral•Weakness•Fatigue

•;noreia•Cange o$ weigt•Fe*er•0um#s•Aigt sweats

' t R i



'ystem Revie46rinary 'ystem•Fre8uency•ysuria

•Urgency•Hesitancy• Terminal !ribbling•Aocturia•Back=loin #ain•"ncontinence

•Caracter o$ urine:color=amount (#olyuria) <timing•Fe*er

.ervous 'ystem•Gisual=Smell=Taste=Hearing=S#ee

c #roblem•Hea! ace•Fits=Faints=Black outs=loss o$consciousness(0%C)•uscleweakness=numbness=#aralysis•;bnormal sensation• Tremor•Cange o$ bea*iour or #syce

5enital system•,ain= !iscom$ort= itcing•iscarge

•Unusual blee!ing•Seual istory•enstrual istory > menarce=0,= !uration < amount o$ cycle=Contrace#tion•%bstetric istory > ,ara=

gra*i!a=abortion

)usculos2eletal 'ystem•,ain > muscle- bone- 5oint•Swelling

•Weakness=mo*ement•e$ormities•4ait



'aat 7oass - )ema2ai '$A%

'ub5ecti*e: ow #atient $eels=tinks about im' How

!oes e look' "nclu!es ,C an! generala##earance=con!ition o$ #atient

$b5ecti*e > rele*ant #oints o$ #atient com#laints=*ital

sings- #ysical eamination=!aily weigt-Dui!

balance-!iet=laboratory in*estigation an! inter#retatio

%lan > about management- treatment- $urter

in*estigation- $ollow u# an! reabilitation

Assessment > a!!ress eac acti*e #roblem a$ter

making a #roblem list' ake !i?erential !iagnosis'

Calgary Cambri!ge



Calgary1Cambri!geCommunication o!el (CC%4)



Tank you

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Ppt 6 - History Taking

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